Transcript Request Form

Transcript Request Form
• Processing time for transcripts is 3 to 5 business days

• Processing time for certificates is 5 to 7 business days

• Transcripts are $3 per copy due with request

• Certificates are $5 per copy due with request

• All tuition/fees must be paid in full
Full Legal Name:*

First NameMiddle NameLast Name
Maiden Name:
Last Name
Last 4 digits of SSN*
Birth Date:*

MonthDayYear
Email:*
example@example.com
Phone Number:*
Please enter a valid phone number.
Approximate dates attended: *
Did you attend in:*

LoganBrigham
Have you received/requested a transcript from BTECH before?*

YesNo
Are you a former/current LPN (Practical Nursing) student?*

YesNo
LPN applicant?*

YesNo
Delivery Method:*

Mail to HomePick up from BTECHE-mail (unofficial transcripts only)Mail to Other School/Business (provide information below)Fax (provide information below)
School Name or Business Name*
Address*

Street Address

Street Address Line 2

CityState

Zip CodeCountry
Authorized person to pick-up transcript.
Will need picture ID at time of pick-up.
Email
If different from the one entered above.
Fax - : (Institution name, attention to, fax number, etc.) - Unofficial ONLY
Need an additional address?

YesNo
Address

Street Address

Street Address Line 2

CityState

Zip CodeCountry
Comments:

Request is For:*

Official transcript Enter description

$3.00 Quantity

Unofficial TranscriptEnter description

$ Free Quantity

CertficateEnter description

$5.00 Quantity

Total

$0.00

Credit Card

First Name

Last Name

Credit Card Number

Security Code

Expiration Month

Expiration Year

Billing Address

Street Address

Street Address Line 2

City

State / Province

Postal / Zip Code

Country

RELEASE ACKNOWLEDGEMENT: I authorize the release of my academic records to the third parties specified on this form. I also approve the delivery method indicated above.
Signature:*

Clear
Date:*

MonthDayYear
Date
How would you like to be notified?*

Please e-mail me when my transcript is ready or sentPlease call me when transcript is ready to be picked up
Should be Empty: